Welch has rather facetiously stated that the motto of the proctologist is onward and upward and this is true in another sense as well.The advance from the days of John of Arderne to the present-day status of the colorectal surgeon being a well-trained abdominal surgeon, as well as a specialist in anal problems, has been long upward climb. In 1936, Rankin stated:
"This huge progress over a period of years in rectal surgery is a monument to these pioneers whose untiring efforts,sturdy courage and maintenance of the highest tradition of the profession, forced progress in a field not too favorably looked upon by general surgeons as a whole because of an unwarrantably high mortality, unpleasant,disease and prolonged and complicated convalescence."
Colorectal surgery, as a specialty, parallels the development of surgery in general. Homans stated that man appears to differ from the four-footed animals in suffering from a great number of painful and disabling anorectal diseases. Whether these diseases were more prevalent in other times is unknown, but there are numerous records of treatment of anal and rectal diseases handed down to us by the ancients.
The Egyptians
The Ebers medical papyrus, c. 1700 B.C., gives 33 prescriptions or recipes for the treatment of anorectal diseases. 'These include ointments, suppositories, enema'; and liniments, most of which had a fatty base, plus prescriptions for cathartics and vermifuges. The Beatty medical papyrus of the 12th and 13th century B.C. consists almost entirely of methods and remedies for treating colon and anorectal disease. The prescriptions contain such ingredients as honey, myrrh, flour, ibex fat, and rectal injections containing honey and sweet beer. Banov, in his review, mentions 41 prescriptions found in the Beatty papyrus which were used to treat such conditions as pruritus ani, painful swelling (probably in thrombosed hemorrhoids), and prolapse of the rectum. Study of this papyrus leads one to agree with Herodotus that there were specialists for colorectal diseases as well as for many other diseases.
The Indians
In the Susruta Samhita(represents arguably the zenith of ancient India’s medical and surgical system. It provides a historical window into a school of professionalized surgical practice over 2000 years ago, during when it almost certainly represented the most advanced school of surgery in the world) recorded between 800 - 600 BC., the treatment of penetrating intestinal wounds was clearly described. In the case of disembowelment, the protruded bowel is carefully examined for injury, anointed with ghee and honey and returned into the peritoneal cavity in its natural position. Lacerations of the intestine were ingeniously repaired with living Bengal black ants that were used to approximate the bowel edges; these ants were then decapitated so that the bowel approximation was maintained. Following anointment with ghee, milk and honey, the bowel was returned to the peritoneal cavity.
The Greeks
Hippocrates (460-377 B.C.) wrote extensively on the diseases of the anus and rectum, as shown by his dissertations "On Fistula" and "On Hemorrhoids."The treatment of these diseases by means of suppositories, ointments, and enemas was much the same as that of the Egyptians. The Greeks seemed to do more in the way of surgery. Hippocrates writes in some depth on the treatment of hemorrhoids by cutting, excising, sewing, binding, and cautery. His directions for the use of the cautery include: "Force out the anus as much as possible with the fingers, make the irons red-hot, and burn the pile until it be dried up, and so as that no part may be left behind .... You will recognize the hemorrhoids without difficulty, for they project on the inside of the gut like dark-colored grapes, and when the anus is forced out they spurt blood. When the cautery is applied the patient's head and hands should be held so that he may not stir, but he himself should cry out, for this will make the rectum project the more.. .. '" Up until the 19th century, hemorrhoids were some• times called "condylomata" and this is a point to be noted in reading the d escriptions of the old authors.
Hippocrates recognized the relationship between the anorectal abscess and the resulting fistula. His treatment of fistula was by a stent or by a ligature technique. In his treatise "On Fistula" he gives the following description of treatment:
"Another method of cure:-Taking a very slender thread of raw lint, and uniting it into five folds of the length of a span, and wrapping them round with a ho rse hair; then having made a director (specillum) of tin, with an eye at its extremity, and passed through it th e end of raw lint wrapped round as above described, introduce the director into the fistula, and, at the same time, introduce the index finger of the left hand per anum; and when the director touches the finger, bring it out with the finger, bending the extremity of the director and the ends of the threads in it, and the director is to be withdrawn, but the ends of the threads are to be knotted twice or thrice, and the res! of the raw threads is to be twisted round and fastened into a knot." , Hippocrates also realized the relationship of the urinary tract to anorectal diseases. Prescriptions for both were often given at the same time. Cutting, a I well as cautery, was often used for hemorrhoids and astringent dressings applied to control the bleeding.
Hemorrhoids were also treated with suppository and they were advised to be opened when they may become ripe. In regard to wounds of the intestine, Hippocrates was of the opinion that all such wounds were fatal, although the ancient Hindu writings, Susruta (6th century B.C.), advised the closing of the wounds of the intestines with the pincers of black ants, washing it off with emoluments and reintroducing it into the abdomen. The first description of an intestinal wound, as frequently quoted, is from the Bible, Judges 2: 3:22, when Eglon was stabbed by Ehud "he could not draw, the dagger out of his belly and the dirt came out."
The Romans
The Romans did not contribute much to the practice of proctology, following for the most part the Egyptian and Greek methods of treatment. However, Cclsus (25 B.c.-50 A.D.) stated that wounds of the intestine should be sutured in all layers and, in "De Re Medica," advocated the use of the knife for anal fistula; for multiple fistulous openings, he recommended that the ligature be used along with the surgery.Galen (129-199 A.D.), despite his great fame and authority, contributed little to the treatment of anorectal diseases.
The Byzantines
Skipping a few centuries, we come to Paul Aegina, 7th century surgeon of the Byzantine period. Paul gives excellent descriptions for the procedures for
hemorrhoidectomy and anal fistula.
"Tile existence of hemorrhoids is rendered manifest to us by the discharge from them. Before proceeding to the operation we must use sequent clysters with the view of evacuating at the same time the contents of the intestine, and by irritating the anus, of rendering it more disposed to eversion and protrusion of the gut. Having, therefore, laid the patient on his back in a clear light, if we are to use the ligature we pass a very thick thread round the lips and ,secure each of the hemorrhoids with this ligature, leaving one as an outlet to the superfluous blood (for so Hippocrates directs). After the application of the ligature, using a compress that has been dipped in oil and the bandage adapted for the anus, we order the patient to remain quiet, ... Leonides has not recourse to the ligature, but having seized the hemorrhoids and held them for some time with the forceps used for operations on the uvula, he cuts them off with a scalpel. ... Others by filling the cavity of the instrument called staphylocaustes, with caustic medicines, have burnt hemorrhoids like a scirrhous uvula.""
The Arabs
Under the Arabs, there was not much improvement in treatment of these diseases, although Maimonides (1135-1204 A.D.) wrote a treatise "On Hemorrhoids" in which he recommended light diet and Sitz baths. He did not believe that this would cure many cases as the cause of the disease would not be attacked directly and he felt that recurrence would be frequent.
School of Salerno
The next step takes us to the School of Salerno where Roger Frugardi ( 1170) or Roger of Salerno, as he was known, is said to have recommended the suture of wounds of the intestine over a stent using the trachea of a large bird or large or large hollow elder twig, according to some authorities. The School of Salerno was noted for its rules of hygiene as set forth in one of the most popular medical books of all time, The Regimen Sanitatis Salerni. The English translation of one of their dictums by Sir John Harrington, a godson of Queen Elizabeth I and inventor of the
modern water closet, is of interest in this regard:
"Great Harmes have grown, and Maladies exceeding, By keeping in a little blast of wind; So cramps and dropsy, colics have their breeding and mazed brains for want of vent behind; Besides we find the stories worth the reading, A certain Roman Emperor was so kind, Claudius by name, he made a proclamation, Escape of wind to be no longer loss of reputation. Great suppers to the stomach much offend, Sup light to sleep intend.'"
During the Middle Ages, sufferers from most diseases had a patron saint whom they could invoke. Saint Fiacre, a 7th century acolyte, was the patron saint of gardeners and eventually became the patron saint of hemorrhoid sufferers. He must have been a popular saint, for in Paris an inn was named after him and featured a statue of the saint. The carriages that stood outside the inn thus eventually assumed the name of fiacres.
Fourteenth Century
If Saint Fiacre was the patron saint of hemorrhoid and fistula sufferers, those who treated these diseases would probably have chosen John of Arderne, born in the year 1307 A.D. His works were studied extensively and translated by Sir D'Arcy Power. Arderne served in the Hundred Years' War under the Duke of Lancaster (John of Gaunt). He began his surgery in Newark upon discharge from the military.
He was particularly interested in diseases of the rectum and anus and described an operation for anal fistula which differs very little from the modern treatment of this condition. He had a very prominent clientele and charged correspondingly large fees which were sometimes paid in the form of annuities. He laid down rules of conduct and urged his followers to cultivate charity and a chaste mode of life,avoiding all harlotry , and to be particularly careful in their conduct with the wives, daughters and other women in the household of their patients. He believed in careful following of his cases and the importance of aftercare; and he reported his failures as well as his successes. He recognized ischiorectal abscesses as a cause of fistulas and urged that they be opened before they ruptured into the rectum. His description of cancer of the rectum is classic and follows:
"Bubo is an apostem breeding within the anus in the rectum with great hardness but little aching. This I say, before it ulcerates, is nothing else than a hidden cancer, that may not in the beginning of it be known by the sight of the eye, for it is all hidden within the rectum; and therefore it is called bubo, for as bubo, i.e. , an owl, is always dwelling in hiding so that this sickness lurks within the rectum in the beginning, but after passage of time it ulcerates and, eroding the anus, comes out. And often it erodes and wastes all of the circumference of it so that ... it may never be cured with man's cure. But if it pleases God, that made man out of nothing, to help with his unspeakable virtue; which , forsooth, is known thus: the leech put his finger into the anus of the patient, and if he finds within the anus a thing hard as a stone, sometimes on one side only, sometimes on both, so that it permits the patient to have egestibn, it is bubo [cancer 1 for certain. Signs, forsooth, of ulceration are these: the patient cannot abstain from going to the privy because of aching and pricking and that twice or thrice within one hour; and he passes a stinking discharge mixed with watery blood. Ignorant leeches will assure the patient, that he has dysentery, that is, the bloody flux, when truly it is not. I never saw nor heard of any man that was cured of cancer of the rectum, but I have known manv that died'of the foresaid sickness."
Sixteenth Century
The 16th century gave us two of the greatest names in surgery. Andreas Vesalius (1514-1564 A.D.), called the Father of Anatomy, and Ambroise Pare (1510-1590 A.D.), military surgeon and surgeon to several Kings of France. However great their contributions to surgery and anatomy, they left very little of interest to the history of colorectal surgery. There are two items of interest in Pare's works, one paper on wounds of the intestine appears under the title "The Guts" in his
essay "How to Make Reports": "When the guts are wounded, the whole body is griped and pained, the excrements come out at the wound, whereat often times the guts breake forth with great violence." The other appears in his "An Apology and Treatise," in which he differs from the authority of Hippocrates:
"Moreover, I should be sorry to follow the saying of the sayd Hippocrates, in the third book, De Morbis, who commands in the disease called Volvulus to cause the belly to be blown with a pair of Bellowes, putting the nosell of them into the
intestinum rectum:, and then blow there till the belly be much stretch, afterwards to give an emollient glister, and to stop the fundament with a sponge. Such practise as this is not made now a day therefore wonder not if I have not spoken of it." •
Seventeenth Century
Concerning the 17th century, Mettler 3 states "Proctologic operations, notably those for hemorrhoids and fistulae, were much the same as we have previously found. ... "
The 17th century, however, produced a notable event. in the form of Louis XIV's operation for fistula.Bettman describes it as follows:
"In 1685, Louis developed a small lump in the rectum. The court doctors and apothecaries failed to remove it, so a surgeon, Charles Francois Felix, was summoned. First he explained to Louis how surgery would bring relief. Then he set the date of operation six months ahead. This gave him time to practice on more lowly patients, the greater part of who died under his knife. They were buried at night, to keep the news from reaching the public ear. Finally, on November 18, 1686, Felix performed the operation at Versailles, in the presence of Madame de
Maintenon and the court medical staff. It proved a complete success. As Louis recovered, his sycophants walked around the court with their bottoms bandaged, to show their sympathy with the King's posterior discomfort. "Felix received 300,000 livres for the job, three times the annual salary of the chief physician. He was made a nobleman, and the year 1686 became known as 'I'anee dela fistule.”
The event was considered of such importance that Michelet considered this "more important than the work of Pare," and Garrison states that this brought about the rehabilitation of French surgery.
The 17-century physician Morgani receives special praise from Charles Elton Blanchard's 1938 classic, The Romance of Proctology.says of him on our behalf: "We are thankful to Morgani that, in the midst of all his many researches, he, of all the great names at Padua, looked into the human rectum, and discovered and named its crypts and pillars.
"It is strange," Blanchard reminds us, "how immortality in medicine is often gained by some very minor contribution.
"Morgani is remembered by the crypts and columns of the rectal outlet; Hilton by his 'white line', which is seldom white in the living subject.
Eighteenth Century
In Paris, in 1701, Jean Mery (1645-1722) performed in a patient, suffering from large bowel gangrene after a strangulated hernia, the first artificial anus, followed by Françoi s-Gigot de la Peyronie (1678-1747) who carried out the same intervention in 1723 and 1743, and Jean-Louis Petit (1674-1750), are announcing in 1718 with success the same procedure. Simultaneously, surgeons tried to create a colostomy not only in cases of intestinal obstruction due to hernias but also due to tumors. Two methods will appear having the same objective, but a different realization: the method of Callisen and the method of Littre.
One year after the death of François Broussais (1772-1838) from rectal cancer, the French surgeon Jean-Zuléma Amussat (1796-1856; who treated Broussais but didn’t dare to realize on his master the technique which he proposed, in 1839, in the Gazette Médicale de Paris entitled “Mémoire sur la possibilité d’établir un anus artifi ciel dans la région lombaire, sans pénétrer dans le péritoine”, had the idea to perform an orifice for the fecal discharge by a section in the descending colon, in the left lumbar region . The part of the bowel to an exterior abdominal orifice that we will never close and which will function as an anus”
The rifle-barrel colostomy and Hartmann’s operation are based on this idea. The first recorded suggestion for enterostomy or colostomy was made by Littre; (1658-1726 A.D.) as reported by Fontanelle in 1710. In part, the incident is described as follows:
'M. Littre'," saw in the dead body of an infant of six days a mal development of the rectum. The rectum was divided into two portions both closed and connected by only a few threads of tissue of about an inch long. The upper portion or the closed bowel was filled with meconium. The lower portion was entirely empty. M. Littre, wishing to render his observations useful, imagined and proposed a very delicate operation in the case where one would recognize a similar conformation. It would be necessary to make an incision in the belly, open the two ends of the closed bowel and stitch them together, or at least to bring the upper part of the bowel to the surface of the belly wall, where',' it would never close, but perform the function of anus. Upon this slight suggestion a clever surgeon could imagine for himself details which we suppress. It often suffices to know in general that a thing may be possible and not to despair of it at first sight.” However the operation was not to be performed for another sixty-six years when it was performed by another French surgeon, Pillore. The extensive, interesting history and case report is quoted by Dinnick in some detail. The surgeon, Pillore, had several of his colleagues see the patient but no one thought he should be operated on. However, the patient, when he knew there was no other release for his obstruction, urged the surgeon to operate. He made a transverse incision of the abdomen and a transverse incision of the cecum and sutured them to the edges of the wound. The patient died 20 days after the operation from erosion of the intestine by several pounds of quicksilver which he had taken, but had been unable to pass either per anum or through the cecostomy.
Pierre Duret (1745-1825), surgeon Major in Brest’s navy, was the first surgeon to perform colostomy in a child. In 1793, thanks to an iliac colostomy, he saved the life of a child affected by anal imperforation. The first colostomy to treat a cancer was a caecostomy and was performed by Pillore of Rouen in 1770. The patient was a wine merchant suffering by large bowel obstruction due a scirrhous carcinoma located at the colorectal junction. The distended caecum was exposed through a transverse section, opened and fixed to the margins of the wound with a couple of sutures. The operation produced great relief of the obstruction but the patient died on the 28th post-operative day because of necrosis of a loop of jejunum produced by the large amounts of mercury amounting to 2 lbs in weight that had been given in the original conservative attempts to overcome the obstruction. This case went unnoticed, although the technique became well-known; an excellent technique and a good post-operative care thanks to a sponge maintained in the caecostomy allowing the faeces deposition. Charles Louis Dumas (1765-1813) Professor of Anatomy and Physiology in Montpelier, then Dean of the Faculty and vice-chancellor of the University, ignoring the operation of Pillore, proposed the left colostomy in a case of rectal cancer (1797) , followed by Pierre Fine (1760-1814), chief surgeon of the General Hospital of Geneva, who carried out the first successful transverse colostomy in 1797. The patient, a woman aged 63 with a recto-sigmoid obstructing growth, lived for 3.5 months before dying of ascites . These two case reports published in Annales de la Société de Médecine de Montpellier remained ignored.
However, the real birth of colostomy as a successful operation occurred in 1793 when Duret performed a left iliac colostomy in a case of imperforate anus in a child three days old. Again, a complete operative note was made and is recorded in Dinnick's paper. The patient survived and lived to the age of 45 years. Desault (1744-1795 A.D.) surgeon-in-chief at L'Hotel Dieu performed the same operation on a two-clay-old infant with an imperforate anus, in 1774. However, he did not suture the edges and the patient died four days postoperatively.
In the 18th century, Morgagni (1689-1771 A.D.) described the crypts and columns which still bear his name and he was the first to propose an operation for cancer of the rectum. According to Meade a posterior resection of the rectum was performed in 1739 by Fajet which resulted in an uncontrollable sacral anus. More important, however, was the study and development of the operation of colostomy which was of great importance in giving experience with surgeon of the bowels which would prove valuable when more extensive operations would be performed later in the Century. Throughout the centuries, physicians acquired considerable knowledge of colostomies from observation of the fistulas caused by trauma or disease.
Lorenz Heister (1683-1758 A.D.) gives this account of state of that knowledge entitled "On the Spontaneous Colitis or Operative Creation of an External Intestinal Fistula in Injuries or Gangrene of Bowel."Or Loss of Substance in the Intestines”
Where any Part of the Intestine is carried away, the case seems to be plainly desperate. It was therefore wonderful that Persons thus wounded did not all die upon the Spot. ' in the Operation of making the Sutures: till various surgeons observed, that the Lips of Intestines so wounded, would sometimes quite unexpectedly adhere to the Wound in the Abdomen: and therefore there seemed to be no Reason why we should not take this Hint from Nature. Whenever therefore a Surgeon is called to a Case of this Kind, after he has diligently examined the State of the Copper Pan of the Intestine, which has suffered a Loss of Substance, he should stitch it to the external Wound, either by the continued or interrupted Suture. For by this means the Patient may not only be saved from instant Death. but there have been Instances where the wounded intestine has been so far healed, that the Faeces which used to be voided per Anum, have been voided by the Wound in the Abdomen: Which, from the Necessity of wearing a Tine or Silver Pipe, or keeping Cloths constantly upon the Part to receive the Excrement, may seem to be very troublesome: But it is surely far better to part with one of the Conveniences of Life, than to part with Life itself. Besides, the Excrements that are voided by this Passage are not altogether so offensive, as those that are voided per Anum.
The same Method of Cure may conveniently enough to be put in practice, where any Part of the Intestine is identified by being forced out of the Abdomen. For in this Case, if you tie up the mesenteric Arteries, the corrupted or mortified Part of the Intestine may be cut off, and the remaining sound Part made to adhere to the Wound of the Abdomen. For it is better to try this Method, though few should be saved by it, than to suffer all to perish, as Celsus observes; It is wiser to attempt a doubtful remedy than absolutely to despair. ronce published a Cure of this Kind in a Dissertation containing various Observations, printed at Heimstadt." ,.
Nineteenth Century
During the first half of the 19th century, interest in colostomy continued and the operation was performed more frequently. In 1810, Callisen, professor of surgery at Copenhagen, wrote concerning Colostomy, and conceived the lumbar colostomy in order to prevent the peritoneal penetration (extraperitoneal colostomy) but didn’t realize it . A French surgeon,Amussat began by studying meticulously the anatomical
region on which the operation was based. He reviewed the literature and found that in a period of 63 years since the time of Pillore's first case in 1776 to his own first case in 1839 there had been 29 cases. Nine of these patients survived: 21 of the operations had been for imperforate anus, of these only 4 survived. All of these 4 had been operated on in Brest, the town where Duret had first performed the operation. Of the remaining 8 adults, 5 had survived and all of these had been operated on by the abdominal route. Amussat attributed the fatalities to peritonitis He realized that the left colon lacks peritoneum. Having tried on cadavers all the surgical procedures for colostomy proposed or executed until then and after numerous experiments on animals, Amussat decided to make a transverse section in the region. The first opportunity to apply his procedure in a patient appeared in 1839. It was the case of a woman presented with intestinal obstruction caused by a rectal growth and on June 2, 1839 Amussat carried out the first successfully extraperitoneal colostomy in the lumbar region. One month later, the patient left for the countryside after a rigorous evaluation by the council of the Academy of Science, François Magendie (1783-1855) and Gilbert Breschet (1783-1845), who were able to notice that the colostomy functioned perfectly and the feces appeared regularly. Amussat practised a second operation on a 62-year-old man with cancer obstructing the upper half of the rectum, resistant to dilatation and cauterization. This operation was performed with the same technique and had the same success as the previous one.
Amussat performed a lumbar colostomy through a transverse incision and laid down some rules for the performance of the operation. He determined the site of obstruction by first, rectal examination; second, the amount of f1uid it was possible to inject into the rectum; and third, when the exact site of the tumor could not be determined he punctured the distended bowel with a small trocar. He advised the operation on the right side (1) when the tumor was too near the site of operation on the left side, (2) when the obstruction was far from the anus, and (3) when the site of the obstruction could not be determined. The importance of colostomy is that it was well suited for the pre-anesthetic and pre-antiseptic days and it gave a certain impetus and moderate amount of experience in surgery of the bowel. Amussat's writings are important to the colorectal surgeon; they are complete, precise and show excel lent study of the cases. Amussat defends his operation in the following statement, "An artificial anus , it is true, it is a grave infirmity, but it is not insupportable. To be able to practise it a surgeon ought to fear to be surprised by a pressing occasion, and he should prepare himself by many repetitions of the operation upon the cadaver."
John Ericson, surgeon of the University College Hospital in London, was a pupil of Amussat and was present at his first operation. 14 In 1841, he published a report giving the following indications for colostomy:
1. Imperforate anus
2. Simple retention of feces which could not
otherwise be relieved
3. Obstruction of the big bowel
4. In cancer of the rectum, as soon as pain becomes severe.
Freer, a surgeon of Birmingham, England, performed the first colostomy in that country in 1815. 13 He was followed by Daniel Pring, of Bath, who performed a left iliac colostomy for obstruction due to cancer of the rectum in 1820. An American, Philip Syng Physick (1768-1837), known as the Father of American Surgery, wrote "An Operation for Artificial Anus" in 1826. Dupuyo'en (1777-1835) in France developed a clamp for treating the spur in artificial anus and wrote of this in 1828. "Before using the instrument on man, I made some experiments on living animals; its effects surpassed my hopes. The parts were always divided in six or eight days, and whenever serous membranes were included between the branches of the enterotome, they were found to adhere on the second or third day, consequently. long before the division which happened only on the seventh or eighth. "This highly important adhesive inflammation extends on each side, along the whole length of the branches often cnterotomc, as well as around its point which it exactly circumscribes. It is accompanied by the signs of moderate inf1ammation, at first weak and easily destroyed; at the end of five or six days, this adhesion is pretty strong. It afterwards becomes cellular, and is as solid as a natural union.
"The action of the enterotome and the division of the parts are never attended by acute pain; the inf1ammation is always limited to the vicinity of the parts, around which it forms a small areola, but never extends to the tissue of the organs. It operates by causing mortification of the included parts, and the solution of continuity resulting proceeds from the fall of a slough which is always in between the blades of the instrument. ... "The cure has not been equally perfect in all these cases. In nine there have remained fistulas of various extents, obliging the patient to wear constantly a bandage in order to prevent the escape of flatus, mucous, bilious or fecal matter. The other twenty nine were radically cured in from two to six months. The fatality has therefore been one in fourteen; and taking away the one who perished accidentally from indigestion, it is reduced to one twentieth of the cases operated upon; a result much more favorable than generally obtained in great surgical operations. Lastly, it is to be remarked, that the last fourth of the patients, although less fortunate and obliged to wear a bandage with a pad, were in a situation incomparably preferable to that in which they had previously existed.'"Dieffenbach (1792-1847) in Germany wrote on the treatment of praeternatural anus in 1834.
Fajet attempted a resection of the rectum posteriorly in 1793, but the first successful operation was performed by Jacques Lisfranc (1790-1847), a surgeon of La Pitie Hospital in Paris.' His first successful perineal or posterior resection of the rectum was carried out in 1826 and, in 1833; he reported nine cases on which he had operated. He recommended treating only lesions that were palpable on digital examination and which were not relieved by other forms of treatment. This operation was carried out below the level of the peritoneal retrof1xion by pulling down and amputating a couple of inches of the rectum. According to Mettler, "although these operations were spoken of as rectal removals, they were really only anal excisions with more or less of the lower end of the rectum taken out and were still only palliative and not curative procedures." Most of the patients died with generalized carcinomatosis within two years. Further interest in disease of the colon, rectum and anus was shown by the publication of several volumes•In England and the United States. British books on anorectal diseases in the first 40 years of the nineteenth century were produced by George Calvert, Thomas Copeland, William White, Fredertck. Salmon, John Hawship, and John Kirby in the United States the first standard book on diseases of the rectum was written in 1836 by Bushe, a man of somewhat mysterious origins, who died very young of tuberculosis, Copeland, whose book was pubiished in 1810 described stenosing cancer of the rectum as much as Joan of Arderne. Frederick Salmon (1796-1868) was an important person in the history of proctology. In 1835, he founded seven bed infirmary known as "The Infirmary for the relief of the Poor Afflicted with Fistula and Other Diseases of the Rectum." In 1854 this became St.Marks Hospital, with twenty-five beds, and St. Marks, in turn, became a fountainhead for the education of colorectal surgeons in England and in this country. The early years of the nineteenth century produced a great interest in the treatment of intestinal wounds and suturing of the intestines. Benjamin Travers (1783-1858), in 1812, made a study of intestinal wounds called "An Inquiry into the Process of nature in Repairing Injuries of the Intestines," citing many experiments on dogs and concluding that it was better to attempt to suture these wounds than merely to perform an ileostomy or colostomy. South, in his English translation of Chelius' "Surgery ," gives a summary of the types of suture in vogue in the first half of the nineteenth century. Another interesting item in the above-mentioned book (Chelius) is an early prototype of the Murphy button. In 1826, Denans was said to introduce "into the upper and lower end of the gut a silver or zinc ring, thrusting it inwards about two lines from each end; he then brings out the two ends together over a third ring, of which the two springs retain the external rings. T he included ends of the intestine mortify, and the rings thereby becoming unfastened are discharged by stool, after they have united the serous
till faces in contact. This experiment in the dog has most successful results."
Perhaps, however, the most important of all methods of suturing was introduced in the same year, 1826, by A. Lembert and the description given in Chelius deserves repetition because of the imporlance and continued popularity of the Lembert
suture: "Lembert holds one lip of the wound, whilst he introduces the fore finger into the cavity of the gut, and with the thumb on the external surface presses and pierces it within two lines and a half from the bleeding edge, allowing the needle to pass about a line between the membranes or the intestine, and again passes it out a line and a half from the edge. After he has thus fastened on the external surface of the intestine a small piece of the serous and muscular coats, or even of the mucous coat, if the two former be not sufficiently resistant, he takes hold of the opposite edges of the wound, finds the point which corresponds to the part already pierced, and pushes in the same needle about a line and a half from the edge, allowing it to pass for a line's space between the coats, and about two lines and a half from the bleeding edge. The other threads are applied in the same manner at a distance from three or four lines. The edges of the wound are then turned inwards by means of a probe, and a simple knot is made upon the probe, after which it is withdrawn. In consequence of stitching, a ridge formed by the edges of the wound, projects into the intestine; externally a groove is seen, where the serous surfaces of the intestines lie close together. If the intestines be cut completely through , the edges of the wound produce an internal circular valve."The freedom given by anesthesia and antisepsis led to the development of more and different operations than had been possible in the past, and, in the case of colorectal surgery, this took two different courses because of the anatomic differences encountered in excising the rectum and in operations on the rest of the colon. Acting on the pioneer work of Lisfranc in 1826 and Pinault in 1824, the perineal excision of the rectum continued to be carried out. Theodore Billroth, the father of visceral surgery, is said to have excised the rectum 12 times between 1860 and 1867, and 33 times between 1868 and 1872.'2 Volkmann reported on excision of the rectum in 1878. Verneuil in 1873 began removing the coccyx routinely to improve exposure and revived interest in the resection of the rectum for carcinoma. He modified the original Lisfranc operation by greatly extending the field of operation. Kocher in 1875 and 1876 began closing the anus with a purse string suture and excising a portion of the sacrum as well as the coccyx. This allowed for more radical excision. In this operation, the colon was brought down and sutured to the anus. In 1878, Harrison Cripps excised the rectum, but did not bring the colon down, merely packing the wound. His patients survived at least fourteen months. One of the greatest contributors to the posterior proctectomy was Kraske who, in 1885, presented his operation to the Fourteenth Congress of German Surgeons. His operation, briefly stated, was to make an incision in the median line from the center of the sacrum to the anus, detach the ligaments and fibrous tissue from the left side of the coccyx and sacrum as high as the third sacral foramen, disarticulate and remove the coccyx and, with a gouge, remove the lower part of the left side of the sacrum in a curved outline to the level of the lower border of the third sacral foramen. The posterior wall of the gut was then freed from connective tissue and muscle and the anterior connections likewise severed. The parts to be removed were carefully walled off with gauze to prevent infection and the diseased segment was removed by transverse division of the gut at least half an inch on either side of the growth. The bowel was drawn down from above and joined in the usual manner to the perianal skin and external sphincter with the division of the peritoneum close to the bowel, as was favored by Kocher. This operation and minor modifications by Hochenegg, Badenhauer, Levy and Rydygier was popular into the twentieth century. In the early 1890's, Maunseli added a great deal to the preoperative preparation of patients by washing out the stomach and rectum, dilating the rectum, cleansing the abdomen, using a water mattress, and wrapping the limbs and chest with wadding. His operation was otherwise little different from previous ones. Vincent Czerny in 1883, finding that he could not complete a resection of the rectum by the sacral route, turned the patient over and completed the operation abdominally, thus introducing the abdominal perineal operation which was to be developed and perfected by W. E. Miles in the early part of the twentieth century.
Three years later, in 1900, R. Kronlein reported to the Berlin Surgical Congress a review of 881 cases of rectal cancer in which the three year survival rate had been 14.8 per cent and the operative mortality had been 19.4 per cent. The deaths of 52 patients were attributed to sepsis. This was the status of the surgical treatment for cancer of the rectum at the beginning of the twentieth century. The operations for resection of the colon followed a quite different course from that of excision of the rectum. Suture methods, as we mentioned before, had been developed as well as colostomy, but a planned, formal resection of the bowel with immediate anastomosis was a rarity as peritonitis was still a major problem. Reybard, in 1823, is said to have resected a portion of the sigmoid flexure in a patient for cancer and performed an end to end anastomosis. The patient lived one year, dying of recurrence. Tiersch's case, in 1843, is the next recorded resection of the colon for acute intestinal obstruction and, as late as 1880, only ten resections of the large bowel were recorded, with seven failures. However, from 1880 to 1890, there were 48 resections with the mortality of 45 per cent. Billroth did a resection with closure of the distal end of the bowel, performing a colostomy with the proximal end, much as in the Hartman procedure. C. Gussenbauer, of Liege, reported a partial resection of the descending colon in 1878 and, in 1879, he and Martin of Hamburg each removed a tumor of the sigmoid colon with glands and mesentery and left a double barrel colostomy. They were followed with the same procedure by Schede and Czerny, thus establishing one of the fundamentals of surgery of the large bowel. W. H. Heineke performed a multiple stage operation of resection of the colon in 1884, placing lb. proximal and distal loop side by side. Then he removed the tumor and sutured the bowel to the abdominal wall and crushed the spur with intestinal forceps later, thus closing the colostomy. This sounds very much like the Miculicz procedure. Robert Weir performed an operation similar to that of Billroth in 1885, bringing out the proximal end a, a colostomy and he found that, of 35 excisions of the colon since 1843, eight had completely recovered. He was the first American surgeon to perform a Successful colon resection. Activity in colon surgery was vigorous between 1880 and 1900. Marshall, in 1882, performed an operation similar to Billroth's, with an additional stab wound incision for the colostomy. Kraussold performed the first successful resection of the right colon in two stages. Other operations were also devised, such as the exclusion of a segment of bowel by colostomy and ileo-sigmoidostomy which were done by Maisonneuvean and Trendelenburg. There were many attempts to find safe methods of anastomosis, plus excisions of the bowel, among which were Magaw's elastic ligature 1891 and Murphy's button in 1892. The Murphy budton, a device which stimulated intestinal anastomosis and simplified the procedure, was used for many years. Other methods, such as the use of vegetable plated as Magill used in 56 cases, and the bone plates devised by Micholas Senn, were also used. Halstead attempted anastomosis over an inflated balloon, at the turn of the century, a great deal of experience had been accumulated on large bowel surgery. Perhaps the most important development was the so-called Miculicz procedure. Bloch, of Copenhagcn in 1890 brought the tumor out of the wound and opened the proximal end of the intestine for decompression and later resected the exteriorized loop, later joining together the end of the resected bowel.This was essentially the Miculicz operation. Although Bloch was the first to perform it, Miculicz performed it in 16 cases, reporting on them in 1902. He had lost only 1 patient , and he has received the credit for this development..The accumulated experience in Europe was considerable, but it was much less in this country if we were to judge from the statistics quoted by Welch at the Massachusetts General Hospital for the year 1908 of 347 operations on the colon, 311 were done for appendicitis, with a death rate of 12 per cent; of 36 other operations, there were 3 for cancer of the colon. There were 108 operations on the rectum, 71 of these were hemorrhoids and only 7 for cancer.
There were 60 operations on the anus, 54 for fistula and 5 for fissures. As can be seen, the incidence of rectal and colon resections in this active hospital was rather slight.
During the nineteenth century, there was an increase in knowledge of the anatomy of the colon and rectum. Contributions were made by John Hilton (1804-1878), President of the Royal College of Surgeons and author of the classical "Rest and Pain," who described the line which bears his name. The muscular tube and coats of the rectum were described by the American anatomist, William E. Horner (1773- J8S3), and Professor D. Gerota in 1855 described the perirectal lymph nodes and lym phatic channels of the rectum and perirectum. Two contributions were made in the way of intestinal suturing late in the nineteenth century. M. E. Connell, in 1892, described the popular and important suture that is still extensively used, and H. W. Cushing, in 1899, delineated his right angle continuous suture. Another phenomenon of the nineteenth century which was very important was the influence of St. Mark's Hospital. It was dominant in the development of proctology and the education of proctologists, both in England and in the United States. Frederick Salmon (1796-1868)founded the hospital. Salmon retired in 1859 and is said to have performed 3500 operations in St. Mark's Hospital without any mortality. Following his tenure, short terms as chief surgeon were served by Robert J. Lane and Peter Y. Gounlin, and, in 1864, William Ailingham took over as chief surgeon of the hospital and retained this position for 24 years. Allingham and his son, who developed the crushing clamp for hemorrhoids, were prominent English proctologists and contributed Allingham's textbook, "Diseases of the Rectum," published in 1873, was the standard textbook for many years. In 1877, Joseph M. Mathews (1847-1928) went to St. Mark's Hospital to study under Allingham, and later became known as the "Father of American Proctology." In 1893, he published an extensive treatise on "Diseases of the Rectum, Anus and Sigmoid" which was the first really credible textbook on the Subject, although numerous small pamphlets and handbooks had been published on the subject. Mathews, together with Pennington, Gant, and Tuttle, formed the American Proctologic Society in 1899 and Mathews was elected as its first president. The avowed purpose of the society was to accumulate and disseminate knowledge and encourage teaching and research pertaining to the colon and rectum. The society continues this activity today as the American Society of Colon and Rectal Surgeon.
Twentieth Century
The first decade of the twentieth century brought forth two of the standardized operations for resection of the colon and rectum for carcinoma. Miculicz, in 1902, reported the mortality of 12.5 per cent, having lost only one patient in his operation. This was essentially the operation performed by Bloch, with the added dimension of excision of regional mesentery and lymph nodes. In 1903, Miculicz reported that an operation for cancer of the colon, which involved resection and immediate anastomosis, carried a mortality of 30 to 50 per cent due to peritonitis. He recommended doing the colon procedure in two stages, and described it as follows: "If now the tumor has been freed and completely enucleated, it is drawn out of the wound, the loop of gut is stitched to the parietal peritoneum with sutures including only the serosal coat and the abdominal wound is closed, leaving only room enought for the loop of the gut. Now, only after the abdominal cavity is completely closed, the tumor is excised, and an artificial anus is established which is closed in two to four weeks according to the usual methods." Of note is that Allingham had done a single case in two procedures in 1895. He added the variation of leaving a clamp on the bowel for 36 hours, a maneuver which was to be refined and popularized by Rankin in the next century.
It is interesting to note that Catell, as late as 1941, in a report from the Lahey Clinic 19 makes the following statement: "As a result of this experience certain deductions have also been drawn relating to technical procedures. All colon resections in the clinic are performed with a modified Miculicz plan of procedure. No resections with primary anastomosis are now being, or have for many years, been undertaken. " In regard to the operation of excision of the rectum for carcinoma, the modern type of operation was introduced in 1907 by W. E. Miles, of London. Miles had been a house surgeon in St. Mark's Hospital at the turn of the century and had originally started with the Cripps operation, but gradually developed his operation so that, finally, the description of what he considered an adequate cancer operation should include was :
1. An abdominal anus (colostomy)
2. Removal of all the pelvic colon
3. Excision of the pelvic mesocolon below the crossing of the common iliac artery and a strip of peritoneum
4. Removal of a group of lymph nodes over the bifurcation
of the common iliac arteries
5. Carrying out the perineal portion of the operation as widely as possible
The Miles operation was originally envisioned as a one-stage operation, but, because of infection and hemorrhage, there were many men who preferred to
do a resection of the rectum in two stages. Two-stage operations were described by W. J. Mayo in 1912, by Robert Coffey and Dan Jones in 1915, and by Mummery,
Paul, Gordon-Taylor in England, and, in addition, by Stone and Lahey in this country.An important modification of the Miculicz procedure was developed in 1930 by Rankin. He stated that his operation removed not only all the mesentery desirable, but the tissues in the immediate juxtaposition to the growth, peritonealized the raw surface, insured the blood supply to the two ends of the bowel, and have the bowel obstructed for 48 to 72 hours. He had a three-bladed clamp, which produced the obstruction and held the bowel in position during the 48 to 72 hour period. An important preliminary to this was the decompression of any obstructed bowel and mechanical cleansing of the bowel. The operation, as
stated by Rankin, was similar to Miculicz's with the additional removal of wide piece of mesentery and the lymph nodes in proximity to the growth. The
steps in the procedure were:
1. Incision over the tumor and exploration of the abdomen
2. Mobilization of the colon bearing the tumor
3. Ligation of the blood supply and dissection of the lymph nodes
4. Resection of the growth between two-bladed clamps with the cautery
5. Peritonealization and closure of the rent in the mesentery
6. Wound closed around the clamp, the growth having previously been excised.
The Miculicz and Rankin operations are seldom performed nowadays. In most cases, the tumor is removed widely with mesenteric lymph nodes and an immediate anastomosis performed. Several of the contributions that have made this possible are better preoperative preparation and postoperative care, particularly the easy availability of transfusions and the introduction of antibiotics. Of special importance is preoperative mechanical cleansing and sterilization of the bowel. Improvements in anesthesia also played an important role.Operations involving the colon and rectum evolved, principally, because of two specific problems, namely trauma and tumor. As these procedures were developed with decreasing morbidity and mortality they were applied to other, more benign, conditions ;among these were Hirschsprung's Disease, idiopathic inflammatory bowel disease, diverticular disease, prolapse of the rectum. Rectal prolapse received a great deal of attention in the earlier medical literature. A comment by Hippocrates states, "eversion of the gut takes place in middle aged persons having piles, of children affected with stone and in protracted and intense discharges of the bowel, and in old persons having mucous concrctions (scybale)."The first treatment to be tried is application of fomentations and reductions, then gradually through the ages curative treatments were attempted by hemorrhoidectomy, incision, cauterization and excision. In Ehelius' "Surgery" 17 in 1843, a bibliography of some of the famous names who have written this subject is given. They include Heister in 1745, Copeland in 1814, Howship in 1820, George Bushe in 1827, Syme in 1828, Salmon and Dupuytren in 1831, May in 1833, Brodis in 1835, and Velpeau in 1841. The operations of Copeland, Syme, and Dupuytren were somewhat similar. Dupuytren describes his operation as follows: " ... the patient is put upon his belly, his head and shoulders low, but his pelvis on the contrary much raised by one or several pillows, for the purpose of rendering the aperture of the anus more distinct. Two, three, four, five, or six, of the radiating folds surrounding the anus, which arc either level or less prominent, arc to be seized with a pair of pincers, with somewhat flattened points, one after another, right and left, and even before and behind, and each fold, as raised, is to be taken off with scissors curved towards the surface, and the cut is then to be continued to the (111 us, or even higher into it; but it is ordinarily necessary only to continue the cut some lines upwards. In less relaxation, two cuts, in greater relaxation, several cuts are to be made on each side. Bleeding and other symptoms do not come on; but usually during the operation there is violent contraction of the sphincter. The wound is to be simply treated, and after scarring, the opening of the anus has proper firmness, and the prolapse docs not recur." The development of many more procedures during the early and middle part of the twentieth century attest to the complexity of the problem. In his review of colon rectal operations at Massachusetts General Hospital in the year 1900, Welch" was struck by the relative absence of operations for colonic polyps, ulcerative colitis, granulomatous illitis and diverticulitis. The incidence of these disease has become noted with increased frequency. The development of the sigmoidoscope, barium enema, all now the flexible fiberoptic colonoscope, has helped increase the frequency of the diagnosis of these diseases.
How useful the experience with early operations for tumors was can be seen in the types of operations used for benign diseases today. Diverticulitis is treated mainly for its com plications, usually by drainage and resection. Ulcerative colitis and its complications are treated, in most part, by total proctocolectomy and permanent ileostomy. Congenital idiopathic dilatation of the colon or Hirschsprung's Disease is usually treated by resection of the aganglionic area and preservation of anal sphincter by some type of pull-through procedure. Crohn's disease is usually treated by segmental resection or Lower proctoco!cctomy. Familial polyposis of the colon and its relative, Gardner's Syndrome, are usually treated by resection and ileoproctostomy. With modern methods, the treatment of colorectal diseases by surgery now meets two of the three ancient admonitions for the performance of surgery; that it should be done tuto (safely), cito (quickly) and
iutlllide (pleasantly). We have mentioned the factors that contributed to tile safety (tuto) of operations: decompression of the bowel, preoperative preparation, use of blood and fluids, better anesthesia, and better postoperativecare.
The jllcunde: these operations are now done with less frequent colostomies and, where colostomies and ileostomies are necessary, there has been much improvemcnt in the training of the patient in the care of Ileostomies which has increased their acceptance.
The third admonition, cito, works somewhat in reverse because of the improved condition of the patient and better anesthesia and the operation can be done more slowly and carefully, which in the end leads to a safer and more agreeable result.
In 1966, Morson establishes the degeneration in familial diffuse polyposis. Gilberstein in 1974, by monitoring for 25 years 18,000 persons by rectoscopy,
and by excising the rectal polyps, obtained a decreased number of rectal cancers. The essential preventive treatment of colon cancer, the polyp’s excision started.
From then on, the discovery of early-stage cancer or better the recognition by colonoscopy and excision of polyps (polypectomy) became the gold standard for the
prevention or cure of this malignancy.
In 1952, A. E. Whipple 20 stated that many surgeons dreaded and shunned colon surgery because of the morbidity and mortality due to of leakage and peritonitis. Today, the colorectal surgeon is a board-certified specialist and possesses all the training to combat these complications. Improved results in therapy of diseases of the colon and rectum will rest on the continued development of fully trained surgeons who have a continuing interest in these problems.
